Considerable evidence indicates that contact with safe natural environments (green and blue spaces) can reduce the risk of common mental health disorders (CMDs) like depression and anxiety. This might be because nature contact is intrinsically motivating and can reduce negative emotions while increasing positive ones. However, we know little about the everyday nature-related motivations, practices, and experiences of those already experiencing CMDs. The research question explored whether nature contact helps manage and aid recovery from CMDs, going beyond its role in risk reduction. 'Green care' and 'green prescription' initiatives suggest this possibility, but evidence mainly comes from small-scale studies with self-selected samples. This study aimed to address this gap by conducting a large-scale examination of everyday green/blue space experiences among individuals currently experiencing CMDs. CMDs were a leading cause of disability in 2015, with significant global impact. While various treatments exist, challenges include access limitations, treatment response variability, and stigma. Safe, complementary approaches with low side-effect risks are needed, and evidence suggests nature contact could be part of a comprehensive treatment package. Longitudinal data analysis shows less psychological distress in years spent in greener urban areas, supported by cross-sectional findings linking greener areas to lower antidepressant prescription rates. Experimental studies show that individuals with CMDs experience greater symptom relief from walks in natural settings compared to urban environments. 'Green care' initiatives (horticultural therapy, care farming, wilderness therapy) and 'blue care' (outdoor swimming, surfing) have reported similar benefits, leading to increased interest in 'green prescriptions'. These initiatives, however, remain relatively small-scale due to concerns about acceptability, feasibility, and generalizability beyond self-selected participants. Depression's 'motivation deficit' and anxiety's 'experiential avoidance' may hinder the success of such initiatives. According to self-determination theory (SDT), external pressure can undermine intrinsic motivation; therefore, pressure to visit nature might be counterproductive. This study used data from an 18-country survey on recreational contact with green/blue spaces to investigate these issues, identifying individuals with CMDs based on self-reported medication use. The survey included questions on intrinsic motivations, visit frequency, experiences during the most recent visit, and perceived social pressure.

The researchers reviewed existing literature demonstrating the positive correlation between exposure to nature and improved mental health outcomes. Studies showed that access to green spaces is associated with lower rates of depression and anxiety. The intrinsic rewarding nature of being in nature is also highlighted as a potential mechanism for this positive effect. However, a gap in the literature concerning the experiences of individuals already diagnosed with CMDs was identified. The limited existing research, primarily from small-scale studies, indicated the potential benefits of nature-based interventions for CMD management. The study also draws upon self-determination theory (SDT), which posits that external pressure can negatively affect intrinsic motivation. This theoretical framework informed the hypotheses regarding the potential impact of social pressure on the nature experiences of individuals with CMDs. The studies cited in the paper support the use of nature-based interventions, but the need for larger-scale, more representative studies was emphasized.

Data was drawn from the BlueHealth International Survey (BIS), administered by YouGov across 18 countries (14 European, plus Canada, Australia, Hong Kong, and California). Samples of approximately 1000 respondents, representative by sex, age, and geographic location within each region, were obtained. Sampling was conducted in four waves between June 2017 and April 2018 to account for seasonal biases. YouGov weights adjusted for selection, non-response, and population biases were used in all analyses. The BIS assessed subjective well-being, visit frequency to various natural environments, local blue spaces and childhood experiences, the most recent blue space visit, water quality, general health and well-being, and demographics. While some questions covered various green and blue spaces, others focused on the most recent blue space visit. CMD status was determined by self-reported doctor-prescribed medication use for depression and/or anxiety in the past two weeks. Intrinsic motivation was assessed using a single-item question on the enjoyment of visiting green and blue spaces (7-point scale). Weekly nature visits were determined by collapsing response options for visit frequency in the last four weeks. Blue space visit well-being was measured by agreement with statements on happiness and anxiety during the most recent blue space visit (7-point scale). Perceived social pressure (PSP) was assessed using a single-item question on feeling pressured by others to visit green and blue spaces (7-point scale). Regression analyses controlled for various socio-demographic and individual-level factors. One-sample t-tests compared mean scores to scale mid-points for intrinsic motivation and visit well-being. Linear and logistic regression models tested hypotheses on visit frequency and well-being, with interaction terms for PSP included. Analyses controlled for country effects and potential clustering within countries. The large sample size and multi-country approach strengthen the study's generalizability, although limitations in the representativeness of the samples and the reliance on self-reported data are acknowledged.

The study found that intrinsic motivation to visit nature was generally high, although slightly lower for those with CMDs, supporting the hypothesis that CMDs affect motivation. Contrary to expectations, those with anxiety were more likely to visit nature weekly than those without CMDs, while those with depression showed no significant difference. Overall happiness during the last nature visit was high, and anxiety was low across all groups. However, those with anxiety reported lower happiness, and all three CMD groups reported higher anxiety compared to those without CMDs, supporting the hypothesis that CMDs affect nature visit experience. Perceived social pressure (PSP) was negatively associated with intrinsic motivation, especially for those with depression, supporting the hypothesis. Higher PSP was associated with lower happiness and higher anxiety, particularly for those with CMDs. Interestingly, higher PSP was also associated with increased likelihood of visits, especially for those with anxiety, suggesting a potential trade-off between visit frequency and positive experience. Covariate analysis revealed significant relationships between socio-demographic factors, CMD status, and various outcomes, such as age, gender, perceived income, employment status, marital status, presence of children, and seasonal variation. These relationships varied across the different outcomes (intrinsic motivation, visit frequency, visit happiness, and visit anxiety).

This multi-country study offers unique insights into the nature-related experiences of individuals with CMDs. While intrinsic motivation to visit nature remained high, it was lower for those with CMDs, consistent with general motivational deficits associated with these conditions. Despite potential experiential avoidance, individuals with CMDs frequently visited nature, suggesting a possible self-management strategy. Natural settings appear to offer calming and stress-relieving effects, though experiences were somewhat less positive for individuals with CMDs. Perceived social pressure, while increasing visit frequency, appeared to negatively impact intrinsic motivation and positive affect during visits. This suggests a need for sensitive 'green prescription' programs that avoid undermining intrinsic motivation and ensuring a positive nature-based experience. The negative association between social pressure and positive experience is particularly important for program design. The finding that individuals with CMDs are still largely using nature suggests its role in self-management, but the less positive experience highlights the importance of designing programs that address the underlying motivational and experiential avoidance issues.

This study demonstrates the importance of considering both intrinsic motivation and the potential negative impact of social pressure when designing and implementing nature-based interventions for individuals with CMDs. Future research should investigate the role of environmental quality in mediating the relationship between CMDs and nature experiences, address the complexity of social pressure, and incorporate qualitative methods to better understand the lived experiences of individuals with CMDs in relation to nature. Further exploration of the impact of different types of natural environments (beyond blue spaces) on varying CMDs is warranted, as is a more nuanced understanding of the causal relationship between social pressure and nature visits. Tailoring interventions to address the specific needs and preferences of each individual with a CMD is crucial to optimizing the effectiveness of nature-based interventions.

The study relied on self-reported data, which may be subject to recall bias and subjective interpretation. The use of medication as a proxy for CMD might have overlooked individuals with CMDs who were not currently taking medication. The focus on the most recent blue space visit may not fully capture the range of nature experiences. The sample, while large and multi-national, might not be fully representative of all populations within each country. The relatively small sample sizes within each country limited country-specific analysis. Further research is needed to validate the findings with objective clinical diagnoses and more detailed assessments of both nature experiences and social pressures.